NCC222158_FRO Submitted_20220617

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the blank.)
Part A. Kingsbury Ridge
1. Project Name
2. Location of land -disturbing activity: County Cumberland City or Township Carvers Creek
Highway/Street Elliot Bridge Rd Latitude 35.2122 Longitude -78.8710
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 18.00
6. Amount of fee enclosed: $ 1 170.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name D. Ralph Huff III
E-mail Address [e-mail]
Telephone [phone]
Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MCCORMICK FARMS LIMITED PARTNERSHIP 910-813-0561
Name
Telephone Fax Number
8195 MCCORMICK BRIDGE RD 8195 MCCORMICK BRIDGE RD
Current Mailing Address
Current Street Address
SPRING LAKE NC
28390 SPRING LAKE NC 28390
City State
Zip City State Zip
10. Deed Book No. 5923
Page No. Q461 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who
are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible
parties on an attached sheet.) If the company orfifm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Kingsbury Ridge LLC
[e-mail]
Name
Email Address
2919 Breezewood Ave
STE 100 2919 Breezewood Ave STE 100
Current Mailing Address
Current Street Address
Fayetteville NC
28303 Fayetteville NC 28303
City State
Zip City State Zip
Telephone [phone]
Fax Number910-213-3012

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
DrRalHpff III Manager - Kingsbury Ridge LLC
T p. or pIt n Title or Authority
I 12 2 21
SignKure Date
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I, Rfv\,A 30LrgV%CL.— ` a Notary Public of the County of Curr,her 1 M 0
State of North Carolina, hereby certify that 1�, q'Co oh MuIt T. appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this a day of 20 r71
':Z�
Notar f
My commission expires , 1 I ILI I I o